FORM - A
Form for seeking prior approval of Central Government under section 2 of the Forest(Conservation) Act,1980 for Diversion of fresh forest area
PART - I
(To be filled up by User Agency)
A. General Details
A-1. Project Details
  (i). Proposal No. : FP/UP/Pipeline/143751/2021   (ii). Name of Project for which Forest Land is required : Proposed Forest Land to be diverted for Laying of 200MM Dia Carbon Steel Pipeline along NH-44 - Sijwaha Tiraha-Bypass Marg Bijoli Over Bridge (Ch. 1.000 to 3.000 Left Side), Jhansi Shivpuri NH-27 (Ch. 1373.920 to 1381.420 Left Side) & Jhansi–Gwalior Road NH-44 (Ch.96.127 to 84.427 left side) in Jhansi (UP)   (iii). Short narrative of the proposal and Project/scheme for which the forest land is required : Forest Land to be diverted for Laying of 200MM Dia Carbon Steel Pipeline along NH-44 - Sijwaha Tiraha-Bypass Marg Bijoli Over Bridge (Ch. 1.000 to 3.000 Left Side), Jhansi Shivpuri NH-27 (Ch. 1373.920 to 1381.420 Left Side) & Jhansi–Gwalior Road NH-44 (Ch.96.127 to 84.427 left side) in Jhansi (UP)   (iv). State : Uttar Pradesh   (v). Category of the Proposal : Pipeline   (vi). Shape of forest land proposed to be diverted : Linear   (vii). Estimated cost of the Project(Rupees in lacs) : 1200   (viii). Area of forest land proposed for diversion(in ha.): 0.636   (ix). Non-forest land required for this project(in ha.): 0   (x). Total period for which the forest land is proposed to be diverted(in years): 99
A-2. Details of User Agency
  (i). Name : ADANI TOTAL GAS LIMITED   (ii). Address1 : 2nd Floor, SARC Raj Estate Building, Jhansi Gwalior Road, Jhansi   (iii). Address2 : NIL   (iv). State : Uttar Pradesh   (v). District : Jhansi   (vi). Pin : 284003   (vii). Landmark : NIL   (viii). Email address : adaniupnoc@gmail.com   (ix). Landline Telephone No. : 0-   (x). Fax No. : 0-   (xi). Mobile No. : 8155077780   (xii). Website (if any) : NIL   (xiii). Legal status of User Agency : Private
A-3. Details of Person Making Application
  (i). First Name: Rajan   (ii). Middle Name: Kumar   (iii). Last Name: Singh   (iv). Gender: Male   (v). Designation: Deputy Manager   (vi). Address 1: 2nd Floor, SARC Raj Estate Building, Jhansi Gwalior Road, Jhansi   (vii). Address 2: NIL   (viii). State: Uttar Pradesh   (ix). District: Jhansi   (x). Tehsil: Jhansi   (xi). Pin: 284003   (xii). Landmark: NIL   (xiii). Email Address: adaniupnoc@gmail.com   (xiv). Landline Telephone No.: 0-   (xv). Fax No.: NIL   (xvi). Mobile No.: 8155077780   (xvii). Copy of documents in support of the competence/authority of the person making this application to make application on behalf of the User Agency:
B. Details of land required for the Project
B-1. Details of proposal seeking prior approval of Central Government under the Act for diversion of forest land for the Project already submitted in the past
List of proposal submitted in Past
S.no Proposal Status. Proposal No. Moef File No. Area Proposed for Diversion(Ha.) Area Diverted(Ha.) Date of In-Principle Approval Date of Final Approval
NIL
B-2. Details of forest land proposed to be diverted
B-2.1 Details of Divisions involved
Details of Divisions involved
S.no Division Name Forest Land(ha.) Non-Forest Land(ha.)
1.Forest Division Jhansi0.6360
Total0.6360
B-2.2 Details of Districts involved
District wise breakup
S.no District Name Forest Land(ha.) Non-Forest Land(ha.)
1.Jhansi0.6360
Total0.6360
B-2.3 Village wise breakup
Villages wise breakup
S.no Village Forest Land(ha.) Non-Forest Land(ha.)
1Raksha to Sijwaha0.0960
2Sijwaha Tiraha to Bypass marg Bijoli0.060
3Sijwaha to Pali Paharii0.090
4Pali Paharii to Daily0.0390
5Rasara to Simradha0.0720
6Simradha to Rund Karari0.0960
7Rund Karari to Ambabai0.0930
8Ambabai to Chandra0.0450
9Chandra to Chirula0.0450
Total 0.636 0
B-2.4 Component wise breakup
Component wise breakup
S.no Component Forest Land(ha.) Non-Forest Land(ha.)
1Adani Total Gas Pipeline0.6360
Total 0.636 0
C. Maps of forest land proposed to be diverted
Division 1. : Forest Division Jhansi
  (i). Area of forest land proposed to be diverted(in ha.) : 0.636   (ii). Nature of the Project: Linear   (b). No. of Segments : One
Segment wise details
Segments Segment Area(in ha.) Kml File of Segments
(To view KML file on google the same may be downloaded and then open if in google earth install in your computer).
1.0.636    View File
  (iii). Copy of Survey of India Toposheet indicating boundary of forest land proposed to be diverted:   (iv). Scanned copy of the Geo-referenced map of the forest land proposed to be diverted prepared by using GPS or Total Station:
D. Justification for locating the Project in forest land and details of alternatives examined:
  (i). Copy of note containing justification for locating the Project in forest land:   (ii). Whether a copy of map indicating location of alternative examine is required to be provided: No   (a). Reason for not providing such map: NA
E. Employment likely to be generated
  (i). Whether the Project is likely to generate employment ?: No
F. Displacement of People due to the Project, if any
  (i). Whether Project involves displacement?: No
G. Details of Cost-Benefit analysis for the Project
  (i). Whether the Project requires Cost-Benefit analysis?: No
H. Status of Environmental Clearance
  (i). Whether the Project requires Clearance under the Environment (Protection) Act 1986 ? : No
I. Status of Wildelife Clearance
  (i). Whether the Project or a part thereof is located in any Protected Area or their Eco sensitive zone? : No
J. Applicability of special provisions governing Scheduled Areas
  (i).Whether the Project or a part thereof is located in a Scheduled Area? : No
K. Status of settlement of rights under the Forest Rights Act,2006 on the forest land proposed to be diverted
  (i). Whether the process for settlement of Rights under the Forest Rights Acts 2006 on the forest land proposed to be diverted has been completed? : No
L. Details of land identified for Compensatory Afforestation
  (i). Whether non-forest or Revenue forest land is required to be provided by User Agency?: Not Applicable   (ii). Whether the area of non-forest land or Revenue forest land required to be provided by User Agency for raising Compensatory Afforestation is less than area of forest land proposed to be diverted ?: Not Applicable   (iii) . Reason for not providing Non-Forest Land: Not Applicable
Additional information Details
Documents
S.No Documents
Remarks
1Grant of Authorization
2NHAI Untertaking
3NHAI Application PDF
4NPV Undertaking
5Power of Attorney
6Route Map
7Forest Notification Gazette
8Undertaking for not start of work.
9Certificate for optional land
10Certificate for NPV
11Undertaking for GOI FN-2014
12Undertaking for Entire Tree Plantation.
13Undertaking for acceptance of UP Govt conditions.
14Certificate for Task Force
15Certificate for WLS
16Certificate for Van Swaroopi area
17Undertaking for CA
18Undertaking for FRA
19Area Calculation sheet